60 PERKINS ST - BUILDING INSPECTION Oo
The Commonwealth of Massachusetts
WE'
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CMR SdMar
Revised Mar 2011
^ Building Permit Application To Construct, Repair, Renovate O e nolish a
�\, 1 One-or Tivv-Family Ihvelling
1 This Section For Official Use Onl
Building Permit Number: to A
.t �' `� to
Bw ding Official(Print Name) �.. Signat - Date
SECTION 1:SITE INFORtNLATION.
Ll Property Address: 1.2 Assessors Map& Parcel Numbers
Co PPrbni 9 �ct MR
1.l a is this an accepted street'?yeses no Nlap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewag�Disposal System:
Public Q( Private CI Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Check if yes13
SECTION2.. PAOPERTYOWNERSHIPL
2.1 Owner of Record:60 1perkin4 flea �f ICQeS CjolSS,,, 141A 0( g6S
. �(Pv
Name(Print) City,State,ZIP
Pjx 91` S!57490 6QV)L-y1gz5®gYhc11�' <
No.and Street Telephone Email ,
SECTION 3: DESCRIPTION OF PROPOSED WORW'(check all that apply) .
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s)X I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Workha_' oc7yi Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Rem Estimated Costs: Official Use Only%
(Labor and Materials
I. Building $ 1. Building PermitFee:S Indicate how fee is determined:
❑ Standard.Cityrrown Application Fee
2. Electrical
0'Cota1 Project Cast (Item b)x multiplier x
3. Plumbing i 2- Other Fees:'S
1. Mechanical (IIVAC) S List:
3. Mech:mical (Fira $ _
'lbtal :11I Fees: 5
Check _No. Check Amount: Cash luwuut
l'ntal Project Cost: S ❑ Paid in Full 11 Outstanchn" Il1llnca 011 —
r
SECTION 5: CO:NSTRUC'I'ION SERVICES
5./I �Construction/S�upervisor License(CSL) Z 13
License Number�— r.ep raven D,uc
Nam--)e oof CAS" l[older�Sd1 List CSL Type(see below)
Iq Y"e 2-L " Type Description
No. and Street
D lJmcr-ic tcd 2 Family
s u el ing cu. lt.
R Restricted ISt2 Fumil Dwallin
City/Town, State, ZIP �( 10asonr
RC Rootin Covering
\VS Window and Siding
G C} O 1 r SF Solid Fool Morning Appliances
I1 0 5-og0 1,f)QD� xbe5 q �}'o ��� I Insulation
'I'cle hone Email address D Demolition
5.2A2egistered Hom Improv ent(CContra_ctor(I11C) J6�� 7 7 2z r
MC Registration txpirAtion Date
I llC�t'uiany i nr,�r{IIC Registrant Name q
NQ. S rcctLM�/CC�Qs 1 g' QR Vq-7 Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the Subject property,hereby authorize
to act on my behalf, in all [natters relative to work authorized by this building permit application.
pet 6)5 941
PrintPrint Owner's Name(Electronic Signature) Date
SECTION 7b; OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Autlwrimd Agent's Name(Electronic Signature) Duty
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www.mass.,,uv/oca Information on the Construction Supervisor License can be found at www.mass.eu�'�IL
2. When substantial work is planned,provide the information below:
Total floor area(sy. 11.) _ _(including garage, finished basement/attics,decks or porch)
tiro; living m-ca(sq. f.) _ habitable room count _
Number of tirephccs._—__------- Number of bedrooms ------___-_-
Numher of badtrnmtts Nuntber,tf hal6baths - _------
I\pc of he,t[iug sy;mitt Number of dx „porches
f}peoFconlin� ;y;tcitt __ ____ f?uclu;cd pen
`fold 111oltet5yuara Foot')-'e" in'tv IIc inh;titn[:,I t;,r_ t',,t.tl hoicct Coo t" ---
CITY OF S.1LE'%V NMASSACHUSETTS
Bl,3MlNG.DEPART\IENT
• 120 WASHLNGTON STREET,3aD FLOOR
has TEL. (978)745-9595
FmX(978) 740-9846
MIBERMY DRISCOLL T HomAs ST.PMUE
NMA
YOR DIRECTOR OF PCHLIC PROPEIETY/HCII.DING COS6�IISSIONER'
Workers' Compensation insurance Affidavit;Builders/Contractors/Electricians/Pitimbers
ApplieanE Intnrtnation Please Print Le ibl
Vase(Ousiness%OrganizatioNindividual): '.
Address:
City/State/Zip:
Are you an employer?Check the appropriate box: - Type of project(required):
1.61 am a employer with t4 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full part-time).• have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet t T• KRemodeling
ship and have no employees,. These sub-contractors have S. ❑ Demolition.
working.for mc.in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp.:insurance'. 5. ❑ We area corporation and its
officers have exercised thew 10.0 Electrical repairs or additions
3.❑ i am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp, c..152,§1(4j,and we have no 12.❑Roof repairs
insurance required.)?. employees. [No workers',. ME]Other '
comp,insurance required.l
' -Any applicam.that checks box sl must also fill out the section below showing their workent'compenmica polity information.
{I hmeownea who submit this affidavit indicating they am doing all wort and then him oWsida contrucrom most sulunil anew affidavit indicating.such
- :Cummlon thug check this boa must anachcd an additional sheet showing the mime of the subcontractors and tkeirworkem`comp:policy infonrintiun. .
l um an employer that is providing gverkers'compensation Insurance for fay employees. Below is the Polley and Job site
irrjonnutioa � � —.
fnsurgnee Company Name.'—
Policy#or Self-ins.Lic.q: Expiration Date_
Job Site Address: City/State/Zip: _
Attacb a copy of the workers'compensation policy declaration page.(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Fine up to S1,500,00 and/or one-year imprisonment,ps well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a Jay against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations'of the DIA for insurance coverage verification. '
l do hereby certify under the palas and penalties o�f¢\�equry that the iiefarmaflon provided aho1vee its I me and correct
Sin 's'r'! �Wt v.t\ (? `itl L� [),are.. to J�
Phone
OJJfciul use only. Do nor write in rh&area,to be completed by city or town oJJfclrrI
City or Town: Pcrinit/Llcense# _
Issuing Authority(circle one):
1. Board of Ileahh 2.Building Department 3.Cilyrrown Clerk 4. Electrical inspector 5. Plumbing Inspector
b.Other
Contact Person: _ Phone it:
w 1
_ CITY OF 5.1. ZNf, NL1SSACHUSETTS
EILLLOLNG DEP.IRTIL&NT
" le � 120 C4.hN6YGT0V STREET, 31a FT.00R
I'EL (978) 745-9595
KIMOFRI EY DR.ISCOLL FAX(973) 7-W-9345
GUYOR .1110MU Sr.PtERM
DITECTO R OF PCOLIC PROPERTY/8t;(LDLYG COSLNIhSIO.V ER
Construction Debris Disposal Affidavit
(required for all demolition and ronuvation work)
In accordance with the sixth edition of the State Building Code, 730 CtbtR section 111,5
Dcbris, and the provisions of N(GL e 40, S 54;
Building Permit hi is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal rauility as defined by,41GL a
It I, S I50A.
The debris will be trnnsportcd by:
4044)w (01,1 4
(lama ul'haular)
The debris will be disposed of in :
S- J-Aha
(Mama of racdity).
WCVM ,
(.iidress ut ti�.ilit�)
,iynanirc ufpermit applicant